IPCEA Shoulder Pain Lindley 2017

Drop-arm Spurling
Yergason Hawkins
Shoulder disorders
• Clavicular fracture
– Most commonly in the middle 1/3 of the clavicle – Usually happen during fall onto outstretched hand – Xray to verify location and possible dislocation – Conservative treatment with sling for 2-4 weeks
Introduction
• Shoulder is one of the most mobile joints in the human body • Shoulder pain is a very common complaint in primary care • Shoulder injuries are frequently caused by excessive, repetitive motions and overuse • The shoulder allows the upper extremity to rotate up to 180 degrees in 3 different planes • It is important to understand the anatomy of the shoulder, mechanism of injury, physical findings, approach to treatment and indications for a referral to specialist
Shoulder disorders cont
• AC joint Sprain and Separation
– Common injury in athletes – Six grades of separation – On exam swelling and tenderness over AC joint – Xray AP view and axillary for more severe dislocations – Treatment for grades 1 and 2 splinting, 3 and higher orthopedic referral
Physical Exam
• Inspection and palpation • Assessment of range of motion and strength • Provocative testing for instability or impingement • Examine neck and elbow to exclude referred pain
Anatomy
History
• Patient’s age, dominant hand, work or sports activity • Shoulder pain scale, quality, location, radiation, aggravating/alleviating factors • Instability of the joint, stiffness, locking, edema • Acute vs chronic • Important to exclude referred pain such as pneumonia, cardiac ischemia, peptic ulcer disease, malignancy
Shoulder disorders
• Scapular fracture
– Uncommon; result from direct blow – Treatment is a sling for comfort with range of motion exercises as soon as pain is manageable to avoid loss of ROM
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Shoulder disorders
• Proximal humerus fracture
– Most commonly caused by direct blow or fall on outstretched hand – Physical exam revels crepitus at site of fracture – Xrays AP and lateral, with Y view if needed to see greater tuberosity – Treatment is shoulder immobilization to prevent external rotation and abduction; surgery for more complicated displaced fractures
Shoulder disorders cont
• Biceps tendonitis
– Results from inflammation of the sheath around the long head of the biceps – Pain and tenderness in the area of bicipital grove – Treatment is rest, icing, NSAIDS and corticosteroid injections – When conservative treatment fails surgery is an option
Shoulder disorders cont
• Rotator cuff tear
– Most common in person older than 40 – When rotator cuff ruptures due to chronic impingement syndrome result is muscular atrophy which limits the needed diagnostic testing – Xrays may show calcific tendonitis of the cuff and superior migration of the humeral head
Shoulder disorders cont
• Dislocated shoulder
– Anterior-most common, patient holds the arm in external rotation and abduction, humeral head palpated anteriorly, diagnosis by dimplቤተ መጻሕፍቲ ባይዱ in the skin beneath the acromion – Posterior-uncommon, patient holds the arm close to the body in abduction and internal rotation, limited external rotation and forward elevation on exam – Treatment is relocation of the humerus and immobilization to permit capsular healing
Shoulder Pain
Katarina Lindley DO, FACOFP Medical Director Palo Pinto General Hospital Rural Health Clinics Mineral Wells, Texas
Learning Objectives
• Understand the role of the Primary Care Physician in the management of shoulder pain • Understand the anatomy and potential causes of the pain • Perform shoulder pain history and physical exam • Recognize the differential diagnosis of the pain • Understand treatment options for shoulder pain
Some Tests for Shoulder evaluation
Test Appley scratch Maneuver Patient touches superior and inferior aspect of opposite scapula Arm lowered slowly to waist Spine extended with head rotated to affected shoulder while axially loaded Elbow flexed to 90 degrees with forearm pronated Forward flexion of the shoulder at 90 degrees and internal rotation Positive results Loss of range of motion-rotator cuff problem Rotator cuff tear Cervical nerve root disorder Bicep tendon problem Supraspinatus tendon impingement
Shoulder disorders cont
• Frozen shoulder
– Results from thickening and contraction of the capsule around glenohumeral joint and causes loss of motion and pain – Slow onset with normal Xrays – Most commonly caused by immobility following a shoulder injury – Diagnosis is clinical – Treatment is physical therapy, NSAIDs and occasionally intra-articular steroid injection